312.1 General Policy

Minimum Essential Coverage (MEC) Reporting to the Internal Revenue Service (IRS) and Individuals, OPS161201 (Published December 6, 2016)

Medical Assistance Program Changes due to the Introduction of Enhanced Federal Medical Assistance Percentage, OPS160305 (Published March 10, 2016)

 

 

Effective January 1, 2014, the Affordable Care Act (ACA) changed Medical Assistance (MA) rules in Pennsylvania. Modified Adjusted Gross Income (MAGI) is the new income methodology used for determining MA eligibility for children through age 18, parents (biological, adoptive or step), caretakers, pregnant women and adults ages 19-64. 

 

MA rules have not changed for individuals whose eligibility is determined on the basis other than MAGI:

 

 42 CFR 435.603(j)

 

The MA category MG is used to identify the majority of MAGI-related budget groups, (See Chapter 305, Appendix E: Medical Assistance Cascade Table). Individuals receiving category MG will be assigned a program status code based on the coverage group.

 

MAGI categories and program status codes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAGI-related budget groups are built using the following target types:
                                                                                                                         

NOTE: MG91 (except MG91P), PC40, PSF15 and PSF14 are built with no target types.

312.11  Eligibility Requirements

The CAO must decide who can get MA using the rules in this chapter and the following chapters:

 

Medical Assistance Eligibility Handbooks

 

 

NOTE: The client must report changes in gross monthly earned income of more than $100 and of gross monthly unearned income of more than $50. All other changes, including new sources of income, must continue to be reported.

 

Supplemental Handbook

 

 

312.12 Pregnant Women and Children under Age One

A pregnant woman or a qualified child up to age 1 can get MAGI-related MA if household income is equal to or less than 215 percent of the Federal Poverty Income Guideline (FPIG) for the household size (See Appendix A).

 

The pregnant woman, once approved, continues to be eligible for MA coverage through the end of the 12th month when the12-month postpartum period ends, regardless of her income or a change in circumstances. (See Chapter 338.42)  

 

The newborn whose mother was getting MA or CHIP at the time of birth can get MA coverage up to age one, regardless of the parents’ income, per the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA).

 

Children under one who were not born to a mother on MA or CHIP at the time of birth are eligible for a 12-month continuous eligibility period (See Section 312.131).

 

NOTE: If the CAO did not know about the pregnancy and learns that cash or MA benefits were closed during the pregnancy, it must approve MA coverage from the date of the closing through the last day of the month in which the 12-month postpartum period ends.

 

Newborns and pregnant/postpartum individuals can only be closed during their periods of continuous eligibility for the following reasons:

 

 

When a provider or other outside source asks for MA benefits for a child under age one, the CAO must review the family’s case record to see if Cash or MA or CHIP benefits were open for the mother at any time during the pregnancy. If so, the CAO must authorize MA benefits for the child from the date of birth until the first birthday.   

42 CFR 435.116

42 CFR 435.117

42 CFR 435.170

312.13 Children Ages 1-5

A qualified child age 1-5 can receive MAGI-related MA if household income is equal to or less than 157 percent of the FPIG for the household size (See Appendix A).

42 CFR 435.118

312.14 Children Ages 6-18

 

A qualified child age 6-18 can receive MAGI-related MA if household income is equal to or less than 133 percent of the FPIG for the household size (See Appendix A).

 

If a child age 6-18 has income under 100 percent of the FPIG for the household size or a child (ages 6-18) with income between 100 and 133 percent of the FPIG with Minimum Essential Coverage (MEC) health insurance, MG00 is assigned.

 

If the child age 6-18 has income between 100 percent and 133 percent of the FPIG without Minimum Essential Coverage (MEC) health insurance, MG19 is assigned.

 

Health insurance may be reported and available to the CAO on applications, renewals, through client reported changes, or Third-Party Liability (TPL) screens in the case record, etc. If the reported health insurance is considered MEC (see MEC Desk Guide  for information about what insurance is MEC), the CAO will check the “Minimum Essential Coverage?” box on the Individual Attributes screen when information is available that shows a child, age 18 and under, has MEC health insurance.  It is important to check this box for all applying children age 18 and under due to changes to category of eligibility that may occur.

 

If health insurance coverage is reported on a new application, on a renewal, or through client reported changes, the CAO will update the MEC indicator on the Individual Attributes screen accordingly. The CAO will not require that the insurance question be answered on the application. The CAO will follow the existing verification policy in Chapter 378.3  to verify health insurance.  

 

NOTE: MA should not be delayed or terminated for an individual whose responsible relative fails to cooperate in identifying and verifying TPL information.  

 

Health insurance may also be systematically updated by TPL batch processes. Any time the CAO takes action on a case with an open MG 19 category, the CAO will review the TPL screens and ensure that the “Minimum Essential Coverage?” box is checked if the TPL screens list MEC insurance.

 

COMPASS Real-Time Eligibility:

Children age 6-18 with household income between 100 and 133 percent FPL with any type of health insurance reported on the application are authorized in the MG 00 category. The reported health insurance and the MEC check box will not be populated in eCIS.  The next time the CAO takes action on the case they must update the MEC indicator on the Individual Attributes screen and review TPL information.

 

For a child age 18, student status will impact the program status code that is assigned. An 18-year old can be eligible as MG27 if they meet all eligibility criteria and they have the following student status:

 

 

If the 18-year old does not have the above student status, MG00 or MG19 can be assigned if all other eligibility criteria are met.

 

312.141 Continuous Eligibility for Children under Age 19

 

Children under age 19 eligible for MA or a Supplemental Security Income (SSI) budget at application or renewal remain eligible for MA coverage in MG 18 C until their next 12-month renewal or until the child reaches age 19, regardless of changes that affect their MA eligibility.  Children in certain MA categories are not eligible for continuous eligibility (See Appendix H).

CAOs must not change the MA renewal date for budgets that qualify for continuous eligibility while aligning other budgets.

The CAO must close children under 19 if:

 

NOTE:  If a child under 19 is ineligible for MA at renewal, the CAO must close the child in Reapplication mode during or after the renewal month.  The CAO should review the case to ensure that the child has received a full 12 months of MA coverage prior to closing the child’s MA budget. The child will be reviewed for CHIP or referred to Pennie (Pennsylvania’s Health Insurance Marketplace) in accordance with existing rules if the child is ineligible for MA at renewal.

 

The CAO must not close children under 19 for:

42 CFR 435.926

When a CAO processes an inter-county transfer for a child who was open for an MA category eligible for Continuous Eligibility and the child is determined ineligible for MA in a new county due to a change in circumstances, the CAO will open the child in MG 18 C with the original renewal date.

312.15 Parents/Caretakers

A parent (biological, adoptive or step) or caretaker can receive MAGI-related MA. The following criteria must be met:

 

 

NOTE: Individuals other than parents with care and control of a child in the MAGI-related household can be caretakers, if the parent is not living in the household. For MAGI-related MA, an individual does not need to be related to the child to be a specified relative in the parent/caretaker category.  Caretakers are individuals age 19 or older.

 

NOTE: If no parents are taking care and control of the child in a household, only one non-parent caretaker is a valid target. If multiple non-parent caretakers are present in the household, only one caretaker will be selected in order of age, oldest to youngest.

 

To ensure the correct MA category is opened for parents/caretakers and unemancipated children age 18 and under, the care and control indicators must be marked on the Relationship screen if the individual is responsible for care and control of a child age 18 or under.

42 CFR 435.110

312.16 Adults Ages 19-64

Individuals age 19-64 can receive MAGI-related MA if household income is equal to or less than 133 percent of the FPIG for the household size (See Appendix A).

 

42 CFR 435.119

 

If an individual age 19-20 has income at or below the  Enhanced MNO limit (See Appendix A), the individual will be assigned category/program status code/target type of MG90N.

 

If an individual 19-64 has a permanent disability (SSA or MRT certified), has income at or below 102 percent of the FPIG, (See Appendix A) and is not entitled to Medicare, the individual will be assigned category/program status code/target type of MG90D.

 

All other individuals 19-64 will be assigned category/program status code MG91.

 

If a woman between the ages of 19-64 is receiving MG90 or MG91 and reports a pregnancy, she will be opened in MG90P or MG91P respectively, and she will remain in MG90P or MG91P until the end of her postpartum period or until the renewal is processed, whichever is sooner.

 

Individuals who report a disability will be evaluated for non-MAGI MA and MAGI MA. 

 

If the individual’s disability is not verified by SSA or MRT, the CAO will review for MAGI eligibility first.  The CAO will review for non-MAGI MA if the individual is not eligible for MAGI MA, or if the individual is determined disabled by SSA or MRT.

 

If the individual’s disability is verified by SSA or MRT, the CAO will review for non-MAGI MA prior to authorizing MG90D or MG91. 

 

NOTE: For MG90 and MG91, the individual must not be eligible for or receiving Medicare.

 

312.17 Benefits

See Chapter 338, Medical Assistance Benefits for information about MA benefits.

 

312.18 Resources

The CAO does not consider resources when deciding an individual's eligibility in a MAGI-related MA category.

 

42 CFR 435.603(g)(1)

 

 

  Updated April 17, 2024,  Replacing September 19, 2023